It’s Not All In Your Head – Mind Body Medicine and Women’s Health

Shawn A. Tassone, MD, FACOG

Saybrook UniversityLa Dea Women’s Health

Institute of Women’s Health and Integrative MedicineJuly 13, 2012Portland, OR

Bullet Slide

• Bullet point• Bullet point

– Sub Bullet

What is Mind Body Medicine?

• Mind-body Medicine is a revolutionary 21st –century approach to health care that includes a wide range of behavioral and lifestyle interventions on a equal basis with traditional medical interventions (Moss, 2003, p.3)

• Mind-Body Medicine focuses on the interactions between mind and body and the powerful ways in which emotional, mental, social and spiritual factors can directly affect health. (Center for Mind-Body Medicine, http://www.cmbm.org)

What is Mind-Body Medicine?

• Partnership (physicians, NPs, psychologists, biofeedback specialists, chiropractors, nutritionists, yoga instructors, spiritual counselors)

• Behavioral and psychosocial interventions are treated as first-line interventions.

• Patient education and self-awareness (self-care)

• Active patient – passive practitioner

Challenges for Primary Care

• Somatization and emotional distress – emotions become physical begins at early age and continues for decades (Quill, 1985)

• 20% of visits to primary care have demonstrable organic causes (Kroenke & Mangelsdorff, 1989)

• One drug prescribed in at least 66% of all PCP office visits (Fletcher, 2010, Forbes Online)

• Response stereotypy– Cardiovascular responders– Gastrointestinal responders– Musculoskeletal responders– Cognitive responders

Challenges for Primary Care

• 65% of patients with anxiety seek treatment for a potential somatic illness (Danton et al, 1994)

• Comorbidities of anxiety and depression in patients with chronic medical disease is essential in understanding the cause of the illness an identifying appropriate treatment (Wayne, Lin & Kronke, 2007)

• Patients with chronic illness account for between 46 and 75% of the costs in healthcare (Moss, 2003, p.7).

• Challenges for the PCP are lifestyle and familial variables and finding a leverage point into the care of the patient before emotions become somatic.

Evidence Based Mind Body Medicine

• Jonas et al (1999, p.73) – epistemology of EBM– Patient preferences and meaning– Mechanisms of action– Safety and efficacy– Treatment effect probabilities in the open clinical setting and

from observational and outcomes research– Precise estimations of effects through systematic summaries

and calculation of confidence intervals when possible– Demonstration of utility and benefit under normal health service

conditions examining the impact of access, feasibility, and costs.

HOW DO WE MAKE IT WORK??

MBM and CAM Therapies

Acupuncture HypnotherapyAromatherapy Manual TherapiesBiofeedback Massage TherapyBiofeedback MassageBioenergetics Nutritional CounselingChiropractic PrayerExercise Spiritual HealingFeldenkrais Tai ChiHerbal Therapy Yoga

What Makes The CAM MBM Paradigm

1. Emphasis on holistic practices and unitary view of mind, body, spirit2. Treating each patient as a unique individual3. Emphasis on a more personal relationship4. Attribute and active role to the patient in the healing process5. Belief in the inherent healing power of the person6. Prescriptions of lifestyle and habit changes7. Emphasis on interventions that elicit healing8. Distrust of invasive treatments that crush the disease but harm the patient9. Belief in eclecticism and empiricism10. Readiness to accept unconventional interventions11. Openness to prayer, meditation and spiritual practices12. Integration of physical, psychological, and spiritual practices

(Freeman & Lawlis, 2001).

MBM and Women’s Health

• Headache• Urinary Incontinence• Fibromyalgia and Chronic Fatigue• Mood disorders• Sleep and Sleep Disorders• Premenstrual Dysphoric Disorder (PMDD)• Temporomandibular and Facial Pain• Spirituality and Healing

Task Force and Levels of Efficacy

• Level 1: Not Empirically Supported – Supported only by anecdotal reports and/or case studies in nonpeer-

reviewed venues. Not empirically supported.

• Level 2: Possibly Efficacious– At least one study of sufficient statistical power with well-identified

outcome measures but lacking randomized assignment to a control condition internal to the study.

• Level 3: Probably Efficacious– Multiple observational studies, clinical studies, wait-list controlled

studies, and within-subject and intrasubject replication studies that demonstrate efficacy.

Task Force and Levels of Efficacy

• Level 4: Efficaciousa. control utilizing randomized assignment, the investigational treatment is shown to be statistically significantly superior to the control condition, or the investigational treatment is equivalent to a treatment of established efficacy in a study with sufficient power to detect moderate differences,andb. The studies have been conducted with a population treated for a specific problem, for whominclusion criteria are delineated in a reliable, operationally defined manner, andc. The study used valid and clearly specified outcome measures related to the problem being treated,andd. The data are subjected to appropriate data analysis, ande. The diagnostic and treatment variables and procedures are clearly defined in a manner thatpermits replication of the study by independent researchers, andf. The superiority or equivalence of the investigational treatment has been shown in at least twoindependent research settings.

• Level 5: Efficacious and SpecificEvidence for Level 5 efficacy meets all of the criteria for Level 4. In addition, the investigationaltreatment has been shown to be statistically superior to credible sham therapy, pill, or alternative bonafide treatment in at least two independent research settings.

Headache and Migraine

• Primary and secondary headache– Primary headaches have no underlying or medical condition

associated with the pain: migraine and tension• Biobehavioral approach

– Assessment– Treatments– Skills Acquisition– Combination therapies

Biobehavioral Approach to Headache

• Biological – the headache comes from food triggers or medical problems and can be treated with medications

• Psychobiological - biology changes affect behavior and conditions of chronic headache involve emotional, cognitive, and behavioral factors. (Moss et al, 2003, p.209)

• An example of this is the cause of headache may be simply stress related causing a migraine but over time the patient symptoms transform into a daily headache. Biological and psychological coping change with chronicity and as such changes must be made – a reprogramming

Assessment of Headachefor the Mind-Body Medicine Practitioner

• In depth clinical interview– Many patients may feel there is serious cause – r/o with medical

work-up. Some also fear they may be told “it’s all in their head”– Attempt to avoid categorizing headaches into organic and or

psychogenic as patients may respond to your questions differently based on your approach

– Medication lists are essential as many patients have been prescribed opioids and NSAID’s

• 80% of of chronic daily headache patients present because of analgesic rebound (Rapoport, 1988; Colas et al, 2004) mainly in women in their 50’s.

– Important to determine the type of headache, triggers, and treatments used

Assessment of Headaches

• Assess if the patient has avoidance behaviors or secondary gain related to the headaches. Some patients phobic of the headache may take meds preemptively as a means to avoid the headache.

• Psychophysiological assessment– Arousal– Electrodermal response– Heart rate and heart rate variability– Respiratory dynamics– Skeletal muscle response– Smooth muscle response

Assessment of HeadacheElectrodermal Response

• Definition– a change in the electrical properties of the skin in response to

stress or anxiety; can be measured either by recording the electrical resistance of the skin or by recording weak currents generated by the body (Merriman’s Dictionary)

• Clinical Uses– Polygraph– Biofeedback devices– E-meter – Scientology

Assessment of HeadacheHeart Rate Variability

• Definition– a measure of the naturally occurring beat-to-beat changes in

heart rate/heart rhythms. It serves as a critical method for gauging human health and resiliency. www.heartmath.org

Heart Rate Variability Devices

Heart Rate Variability Devices

Wild Divine

Assessment of a HeadacheRespiratory Dynamics

• RESPeRATE as example

Assessment of a HeadacheSkeletal and Smooth Muscle Response

• Guarding responses in the muscles of the head and neck or back

• Tenderness in certain muscle groups• Twitching• Trigger points• Patient history and story• Combine the location and severity of the pain with the

narrative the patient gives you and look beyond the obvious.

Treatment

• The best approach for headache is usually multi-dimensional (Moss 2003, p.213)– Education of triggers– Cognitive strategies and coping mechanisms (relaxation

response (Blanchard et al)• MBSR• Progressive relaxation and body scans• EMG assisted relaxation• Thermal control (thermistor)

– Self-regulation with headache diary– Dietary and behavior change– Adherence to drug regimens

Temporomandibular Disorders

• TMJ disorders cause tenderness and pain in the temporomandibular joint (TMJ) — the joint on each side of your head in front of your ears, where your lower jawbone meets your skull. This joint allows you to talk, chew and yawn. TMJ disorders can be caused by many different types of problems — including arthritis, jaw injury, or muscle fatigue from clenching or grinding your teeth. In most cases, the pain and discomfort associated with TMJ disorders can be alleviated with self-managed care or nonsurgical treatments. Severe TMJ disorders may need to be treated with dental or surgical interventions. (Mayo Clinic, 2012)

TMJ – Medical History

• Injury• Dental Work• Gender and Age

– Women three times more likely than men

• Biopsychosocial approach– Psychological history– Social history– Behavioral issues

TMJ – Psych and Behavioral

• Patients more likely to suffer from depression due to chronic pain (Goto, 2009), and may elicit more anxiety

• Patients may have changed social life to accommodate the inability to open mouth – soft foods or not going out to restaurants

• Increased sick days from wok• TMJ patients reporting myofascial or muscular pain may

also have a concomitant psychological disorder that can be diagnosed through investigative medical questioning (Glaros, 2001).

TMJ – MBM Interventions

• EMG biofeedback to aid the patient in decrease functioning where focus is on relaxation of the mouth and not allowing the teeth to touch

• Ask patient to stop chewing ice, nails, or gum• Studies have shown that teaching patients generalized

relaxation skills with instructions to help avoid tooth contact was most successful in reducing pain

• EMG based nocturnal alarms for patients with significant grinding during sleep

Urinary Incontinence

• Determine the type of incontinence

– Stress urinary incontinence

– Overflow Incontinence

– Detrusor instability or Urge Incontinence

– Mixed

– Intrinsic Sphincter Deficiency

Urinary Incontinence - Kegels

• Who knows exactly how to do it• Mostly ineffective if simply described to patients and

more effective when combined with pelvic examination to show levator ani and pelvic floor musculature.

• 5-10 second contractions followed by similar period of relaxation

• Primarily effective for stress incontinence and could worsen urge or detrusor instability

• More efficacious in women with mild symptoms• Vaginal weights effective for SUI (Herbison, 2009)

Pelvic Floor Electrical Stimulation

• Patients treated with a self-help 8 week course and Kegel-type exercises had improvement but not as significant as patients enrolled in a similar program in an incontinence clinic– Quality of life was improved in both groups but more significantly

in those women undergoing a clinical program with a biofeedback device

– Timed voiding and habit voiding

Fibromyalgia

• American College of Rheumatology diagnosis of 11 out of 18 tender points

• Sleep disturbances, poor immediate recall• Poor concentration• Irritable bowel syndrome• Headaches• TMJ• Predominantly female (80%) between 40-64 (White et al,

1999)• Myofascial pain and fibromyalgia are comorbid in many

cases

Fibromyalgia and Myofascial Pain

Features Fibromyalgia Syndrome Myofascial PainMusculoskeletal Pain Widespread Mainly regional

Tender points Multiple Regional

Referred Pain Minimal Follows patterns

Fatigue Dominates Variable

Poor sleep Dominates Variable with pain

Headaches Common Common

Irritable Bowel Common Rare

Pain medications Long term Possible short term

Providers Sometimes multiple Depends

Treatments

• Be aware of patients using long term analgesics and opiates and do not ask them to stop these medications quickly

• Combination of medications and naturopathic treatments significantly reduced symptoms (Teitelbaum, 1999)

• Donaldson (2001) explored the effects of long term pain on the nervous system. The more it is stimulated the easier it becomes stimulated (neuroplasticity)

• Difficult to treat as Donaldson believes the causes are neuroplastic, cognitive, and come from childhood learning processes. Treatments with multi-modalities like SEMG progressive muscle relaxation are recommended

Fibromyalgia – Other Therapies

• High intensity exercise has improved symptoms for some and worsened for others

• Feldenkreis – gentle movement of the muscles while over stimulating the nerves

• TENS units are not recommended• Muller (2001) reported a combined therapy:

– sEMG and biofeedback– Massage– EEG and neurotherapy– 10% had increased pain– 25% had a complete resolution of pain– 65% had reduction of pain in varying degrees

Fibromyalgia Thoughts

• Often a frustrating and debilitating process for patients.• It appears that brain function and learned neroplastic

events contribute to the pain process which then make other stimuli appear more painful.

• Multiple modalities such as medications, movement, supplements, MBM, and cognitive therapies have helped some and worsened others

• Let us remember that first and foremost we are to do no harm

Chronic Fatigue Syndrome

• What patients are using (Neisenbaum 2001)

– Vitamins (79%)

– Exercise (64%)

– Dietary changes (54%)

– Herbal treatments (37%)

CFS – Mind Body Therapy

• Acupuncture– Wang et al (2009) – meta-analysis of 28 studies showed the therapeutic effect of

acupuncture in CFS was superior to control• Guided Imagery and Hypnosis

– Bernardy (2011) meta-analysis failed to show significant reduction in symptoms but studies have had poor methodology due to poor follow up

• Biofeedback and progressive relaxation reported as Level 2 – probably efficacious (EMG being the most common modality utilized)

• Cognitive Behavioral Therapy – somatic symptoms are perpetuated by errant illness beliefs and maladaptive coping (Moss, 2003, p.340).

– 70% of participants undergoing combination cognitive and behavioral therapies reported a decrease in symptoms. Difficulties with CBT are finding a qualified therapist and that treatment is better if one-on-one as group therapies have not been shown to be effective.

Premenstrual Dysphoric Disorder PMDD

• Biological causes

• Psychological components

• Daily log of symptoms

• Societal views

• Hysteria

PMDDNonpharmalogical Treatments

• Change the diet to reduce salt, caffeine and alcohol– Add magnesium and calcium along with DHA and EPA– Smaller frequent meals decreased carbohydrates

• Cognitive Therapy (Steiner, 2000)– Problem-solving– Reframing or looking at problems from other vantage points– Stress management– Interpersonal Competency– Education about PMS

• Wise Guide Imagery

Mood and Sleep Disorders

• Depression

• Dysthymia

• Bipolar

• Depressive Symptoms

• Postpartum Blues and Depression

Mood and Sleep DisordersFuture Directions

• EEG Biofeedback or Neurofeedback

Brainwave Cat Ears

Sleep Problems in Women

• Hormonal imbalance lends a special issue with women’s studies and as such most have been done on males

• Women with PMDD have a higher incidence of sleep disorder (Lee et al, 1990)

• Patients with mood disorders also have a higher incidence of sleep disorder

• Pregnancy can also be a lengthy time of sleep disorder due to progesterone

• Menopause also a state of increased sleep disorder

Mind-Body Therapies and Sleep

• Yoga and sleep – Khalsa (2004) demonstrated that individuals practicing yoga each day for eight weeks had a significant reduction in insomnia

• Manjunath (2005) demonstrated that elderly patients practicing yoga had a shorter time span falling asleep and slept longer.

• Irwin (2008) in a small study of 112 individuals discovered that 25 weeks of Tai Chi practice improved sleep quality in individuals who had a moderate complaint profile of falling asleep

Spirituality and Healing

• Incorporate ritual and ceremony into the process of healing.

• Know the spiritual background of your patient• The Spirit Catches You and You Fall Down – Anne

Fadiman• Allopathic or Allopathetic?• Is there a place for spirituality in medicine ?• Roman Catholic church list spiritual crises and similar

symptoms in their book on exorcisms (Karpel, 1975)

Spirituality and Healing

• Applications of Spirituality in Healing (Koenig, 2001, p.214-219)

– Meaning and purpose in life– Intrinsic values– Transcendent belief– Community relationships

• Individuals with internalized spiritual and religious dimensions score higher on measures of mental health (Moss, 2003, 195).

Spirituality and ReligionA Piece of the Mind-Body Paradigm

• Individuals who attend religious services once a week live longer than those who do not compared to similar controls

• High blood pressure and heart disease are less common amongst religiously oriented people

• (Koenig, 2001, p.249) demonstrated a link between spirituality and heart disease in terms of prevention and decreased treatment procedures.

• If health care providers could participate in spiritual awareness health care would more closely reflect the wholeness and integrity of individuals

Biofeedback Devicesstress thermometer

$21.95 on Amazon – measure vasodilation (headaches and stress)

Biofeedback Devicesstress dots

$12.95 comes with instruction cards and dots www.stressdot.com

Biofeedback DevicesemWave2 by Heartmath

$229 on Amazon. Comes with computer program and readoutGreat for personal and office use, teaches breathing and heart Rate variability compliance www.heartmathstore.com

Biofeedback DevicesOh No!

Questions?

References

• Blanchard, EB, Appelbaum, KA, Radnitz, CL, Morrill, B, Michultka, D., Kirsch, C., Guarnieri, P, Hillhouse, J, Evans, DD, Jaccard, J, & Barron, KD (1990). A controlled evaluation of thermal biofeedback and thermal biofeedback combined with cognitive therapy in the treatment of vascular headache. Journal of Consulting and Clinical Psychology, 58, 216-224.

• Colas et al. (2004). Chronic daily headache with analgesic overuse: Epidemiology and impact on daily life. Neurology, 62(8), p. 1338-1342• Danton et al, (1994). Nondrug treatment of anxiety. American Family Physician, 49(1), 161-166.• Donaldson, C.C. (2001). http://www.practicalpainmanagement.com/pain/myofascial/fibromyalgia/neural-plasticity-model-fibromyalgia-theory-

assessment-treatment-part-1?page=0,3• Fletcher, K (2010). Ten most common health complaints. http://www.forbes.com/2003/07/15/cx_kf_0715health.html• Freeman, L.W. & Lawlis G.F. (2001). Mosby’s complementary and alternative medicine: A research-based approach. St Louis, MO. Mosby.• Glaros, A.G. (2001). Emotional factors in temporomandibular joint disorders. Journal of the Indiana Dental Association, 79(4), 20-23.• Goode PS, Burgio KL, Locher JL, et al. Effect of Behavioral Training With or Without Pelvic Floor Electrical Stimulation on Stress Incontinence in

Women: A Randomized Controlled Trial. JAMA. 2003;290(3):345-352.• Goto, K et al. (2009). Intractable depression successfully treated with a combination of autogenic training and high-dose antidepressant in

department of otorhinolaryngology: a case report. Cases Journal, 2, 6908• Herbison, G.F. (2009). Vaginal weights for training pelvic floor muscles to treat urinary incontinence in women, Cochrane Library.• Jonas, W.B., Linde, K. & Wallach, H. (1999). How to practice evidence-based complementary and alternative medicine, in WB Jonas & JS Levin

(Eds.), Essentials of complementary and alternative medicine (pp. 72-87). Philadelphia: Lippenctt Williams & Wilkins • Kroenke, K ., & Magelesdorff, A.D. (1989). Common symptoms in ambulatory care: Incidence, evaluation, therapy and outcome. American

Journal of Medicine, 86(3), 262-266,• Moss, D. (2003). Mind-Body medicine, evidence-based medicine, clinical psychophysiology, and integrative medicine. In Handbook of Mind-

Body Medicine for Primary Care (Moss, D., McGrady, M., Davies, TC., and Wickramasekera, I. Eds), p. 3-18. Sage Publications. Thousand Oaks, CA.

• Quill, T.E. (1985). Somatization disorder: One of medicine’s blind spots. Journal of the American Medical Association, 254, 3075-3079.• Rapoport, A.M. (1988). Analgesic rebound headache. Headache, 28, 662-665.• Wayne, K. Lin, E.H & Kronke, K. (2006). The association of depression and anxiety with medical symptom burden in patients with chronic

medical illness. General Hospital Psychiatry, 29(2), 147-155.• White et al, (1999). The London fibromyalgia epidemiology study: The prevalence of fibromyalgiasyndrome in London, Ontario. Journal of

Rheumatology, 26(7), 1570-1576

References

• Irwin MR, Olmstead R, Motivala SJ. "Improving sleep quality in older adults with moderate sleep complaints: A randomized controlled trial of Tai Chi Chih." Sleep. 2008 1;31(7):1001-8.

• Karpel, C. (1975). The Rite of Exorcism. New York. Berkeley.• Khalsa SB. "Treatment of chronic insomnia with yoga: a preliminary study with sleep-wake diaries." Appl Psychophysiol Biofeedback.

2004 29(4):269-78• Koenig, H.G. (2001). Handbook of religion and health. New York. Oxford University Press.• Manjunath NK, Telles S. "Influence of Yoga and Ayurveda on self-rated sleep in a geriatric population." Indian J Med Res. 2005

121(5):683-90.